INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on December 18, 2008.
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Plan of Correction
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document complete aftercare plans in one of one client record. The findings include: Five client records were reviewed on November 18, 2008. After care plans were required in one client record. The facility failed to document aftercare plans with measurable goals and support services in client record #4. The aftercare goals were not measurable and support services were missing in client record #4.
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Plan of Correction
Continuing care plans should include measurable goals including support services to achieve such goals. The executive director will retrain staff to include client's specific goals and their supports. The executive director will train and supervise staff on the improvements to continuing care plans by 2/15/09. |